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ADULT UROLOGY

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MINIMIZING KNOT TYING DURING RECONSTRUCTIVELAPAROSCOPIC UROLOGY

ARIEH L. SHALHAV, MARCELO A. ORVIETO, GARY W. CHIEN, ALBERT A. MIKHAIL,GREGORY P. ZAGAJA, AND KEVIN C. ZORN

ABSTRACTbjectives. Intracorporeal knot tying during urologic reconstructive surgery is one of the most technically

hallenging skills of laparoscopic surgery. We describe our experience using the Lapra-Ty clip to substituteor knot tying.

ethods. Our technique for minimizing knot tying entails the use of the Lapra-Ty clip during closure of theollecting system and renal parenchyma for laparoscopic partial nephrectomy, the vesicourethral anasto-osis during robotic laparoscopic radical prostatectomy, and the collecting system during laparoscopicyeloplasty. From October 2002 to July 2005 at our institution, 75 patients underwent laparoscopic partialephrectomy, 300 underwent robotic laparoscopic radical prostatectomy, and 14 underwent laparoscopicyeloplasty. We reviewed the charts retrospectively for intraoperative and postoperative parameters relatedo the use of these clips.esults. In the laparoscopic partial nephrectomy group, the mean tumor size, warm ischemia time, andstimated blood loss was 2.53 cm, 30.1 minutes, and 189 mL, respectively. Two postoperative urine leaks2.7%) developed, and 3 patients experienced postoperative bleeding (4%). In the robotic laparoscopicadical prostatectomy group, the mean operative time was 295 minutes and the mean estimated blood lossas 303.6 mL. Only 3 patients had a urine leak (1%), and 4 patients had bladder neck contracture (1.3%).ith regard to the laparoscopic pyeloplasty group, the mean operative time and estimated blood loss was

24 minutes and 36 mL, respectively. No intraoperative complications or urinary leaks occurred.onclusions. Using the Lapra-Ty clip, we have safely and efficiently supplemented knot tying in patientsndergoing reconstructive laparoscopic surgery. UROLOGY 68: 508–513, 2006. © 2006 Elsevier Inc.

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aparoscopic radical nephrectomy has rapidlyevolved into the standard of care for patients

ith localized renal tumors1 since its introductionn 1991.2 However, reconstructive laparoscopicurgery in which substantial knot tying is neces-ary, such as laparoscopic partial nephrectomyLPN), laparoscopic radical prostatectomy (LRP),nd laparoscopic pyeloplasty (LP), has had slowerdoption rates in the urologic community. This hasargely been because of the high level of difficultyelated to these procedures. In this study, weresent a modification to simplify these proceduressing the Lapra-Ty clip (LTc; Ethicon Endosur-

rom the Section of Urology, University of Chicago Pritzkerchool of Medicine, Chicago, IllinoisReprint requests: Kevin C. Zorn, M.D., Section of Urology,

epartment of Surgery, University of Chicago Pritzker School ofedicine, 5841 South Maryland Avenue, MC6038 J-653, Chi-

ago, IL 60637. E-mail: kevinzorn@hotmail.comSubmitted: December 20, 2005, accepted (with revisions):

7arch 29, 2006

© 2006 ELSEVIER INC.08 ALL RIGHTS RESERVED

ery, Piscataway, NJ) during knot tying. The LTc isesigned to substitute for a knot,3 thereby mini-izing intracorporeal knot tying. It also reduces

he “cheese slicing” effect of the suture wheninching a knot, such as can occur during conven-ional knot tying. In contrast to knot tying, the LTclso permits the surgeon to apply additional ten-ion if needed. The clip is composed of absorbableolydioxanone and can be applied to a singletrand of 1-0, 2-0, 3-0, or 4-0 suture. The clipaintains tensile strength for 14 days and is com-

letely absorbed by 90 days.4 We assessed the fea-ibility and specific complication rates related tohe use of the LTc in all LPN, robotic LRP (RLRP),nd LP procedures performed at our institution.

MATERIAL AND METHODS

All data were retrospectively reviewed with the approval of thenstitutional review board. From October 2002 to July 2005, 75atients underwent LPN for clinical Stage T1a (n � 67), T1b (n �

), or T2 (n � 1) renal tumors. A single surgeon (A.L.S.) per-

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ormed all LPN and LP procedures. A total of 300 patients under-ent RLRP from February 2003 to July 2005. Two surgeons

A.L.S. and G.P.Z.) performed all procedures. Finally, 14 patientsnderwent LP from November 2003 to July 2005; all proceduresere performed by one surgeon (A.L.S.).

ECHNIQUE FOR MINIMIZING KNOT TYING DURING LPNOur technique for eliminating knot tying during LPN has

een previously described.5 In brief, 6-in. 2-0 Vicryl suturescoated polyglactin 910) on CT-1 needles and 6-in. 3-0 Vicrylutures on SH needles with an LTc at the tail end of eachuture were used. After tumor excision and argon beam coag-lation, the 3-0 sutures were used to close the collecting sys-em and open-ended vessels. If any suspicion regarding mar-in status was present, deep tumor bed biopsies were sent forrozen section analysis.

Once a figure-of-eight or running suture was completed, theeedle end of the suture was cinched to the desired tensionnd a second LTc was placed on the suture at the level of theissue. The renal parenchymal defect was then repaired using-0 Vicryl sutures starting at the capsular surface. Once theesired tissue compression was achieved, a second LTc wasinched down to the level of the tissue. Sometimes, additionalension might be needed on the suture to ensure hemostaticompression. Another LTc can be applied more proximally torovide additional tension. FloSeal (Fusion Medical Technol-gies, Mountain View, Calif) was then applied to the exposedefect. Excess tension should be avoided, especially with thedditional tension that will be created by unclamping the renalrtery. This auto-tension is created by the increased tissueurgor related to the return of blood flow.

Standard postoperative drain management included routineemoval of the Foley catheter the morning after surgery, withhe Jackson-Pratt drain removed later that same afternoon ifo increased output was noted.The warm ischemia time (WIT) and postoperative compli-

ations related to the use of the LTc, such as urinary leak andleeding, were assessed.

ECHNIQUE TO MINIMIZE KNOT TYING DURING

ESICOURETHRAL ANASTOMOSIS OF RLRPOur RLRP technique has been previously described.6 Before

e had performed RLRP, we were using LTcs with our pureaparoscopic prostatectomy technique. Because of surgeonreference, we have continued using the clips for the roboticechnique. The vesicourethral anastomosis was performed us-ng a double-armed, van Velthoven suture7 composed of 3-0icryl and 3-0 Monocryl, each 6 in. in length and connected at

he terminal ends by a hand knot and LTc. The anastomosisas begun at the posterior bladder neck (6-o’clock position),

unning the left arm of the suture toward the 11-o’clock posi-ion. On completion, the suture line was cinched with an LTct the level of the tissue. The same sequence was repeated onhe right side. The assistant delivered constant tension on theuture with a grasper as the surgeon ran each respective bitentil the LTc was placed. In all cases, the bladder was thenlled with 120 mL of saline to verify a watertight closure.ostoperative complications related to the vesicourethralnastomosis, such as urinary leakage, bladder neck contrac-ure, and urinary retention, were assessed.

ECHNIQUE TO MINIMIZE KNOT TYING DURING LPAfter dismembered pyeloplasty, a 6-in. 3-0 Vicryl suture

as anchored at the spatulated ureteral apex and free-handutured to the lateral apex of the renal pelvis opening. Theosterior wall of the renal pelvis was then sutured in a runningashion over a ureteral stent and secured with an LTc. The

nterior closure was performed in the same sequence. If a f

ROLOGY 68 (3), 2006

efect remained in the renal pelvis, it was closed using addi-ional suture.

Similar postoperative drain management as that for the LPNroup was used for the LP group. Perioperative complicationselated to the collecting system closure, such as urinary leak-ge and bleeding, were assessed.

RESULTS

The perioperative variables of the patients whonderwent LPN are presented in Table I. The meanumor size was 2.53 cm (range 1.2 to 8.5). Theverall mean estimated blood loss was 189 mL. Theean WIT was 30.1 minutes (range 13 to 55). In

4 (64%) of 69 patients, the collecting system wasntered while excising the renal tumor. In this sub-et group of patients, the mean WIT was 34.6 min-tes. In the remaining 25 patients who only re-uired closure of the renal parenchyma, the meanIT was 26.4 minutes. Four patients (5.3%) bled

ntraoperatively and required urgent open conver-ion. Of these 4 patients, 1 had a renal artery injurynd one procedure was attempted on a complexosniak 3 renal cyst with no hilar clamping. Threeatients (4%) bled postoperatively, two immedi-tely in the recovery room, who required urgentpen exploration and completion nephrectomy,nd one on postoperative day 2 who stabilized afterransfusion of 2 U of blood. Two patients (2.6%)ad urine leaks in our series; both were treatedonservatively with prolonged drainage. One pa-ient had a positive surgical margin, and the proce-ure was converted intraoperatively to open partialephrectomy. One other intraoperative conversionas required because of a tumor location adjacent

o the hilar vessels.The perioperative variables for the RLRP group

re also presented in Table I. The mean operativeime in our series was 295 minutes, with a meanstimated blood loss of 303.6 mL. Seven patientsequired open conversion: two because of bleed-ng, two because of poor tissue dissection, one be-ause of bladder perforation, one because of rectalnjury, and one because of a bladder urothelial tu-

or at the bladder neck. All such conversions oc-urred within the learning curve of the initial 40ases. The mean hospital stay was 1.53 days. Theoley catheter was removed at a mean of 6.1 daysostoperatively. Cystography was routinely per-ormed in the first 30 patients in our series. There-fter, the Foley catheter was removed on postoper-tive day 6. Cystography was only performed inhose patients in whom prolonged drainage wasoted. Overall, 3 patients had postoperative uri-ary leakage (1%) detected by cystography. Oneatient had initially developed a urine leak morehan 2 days after surgery. The cystographic find-ngs on postoperative day 7 were normal; there-

ore, the urinary catheter and abdominal drain

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ere removed at that time. Two patients demon-trated a very small leak on initial cystography. Theatheter was removed on postoperative day 10 and3, after a repeat study with normal findings. Fouratients (1%) developed bladder neck contracturesequiring endoscopic management.The perioperative details for the LP group are

resented in Table I. Four patients had undergonerevious retrograde endopyelotomy as their pri-ary treatment. All cases were performed trans-

TABLE I. Perioperative variables of paariable LPN

atients 75reoperative dataMean age (yr) 60.9 (23–83)Sex

Male 37Female 38

LateralityLeft 31Right 44

Mean tumor size (cm) 2.53 (1.2–8.5)Stage

cT1ccT2acT3b

Mean PSA (ng/mL)Gleason score

5–6789

perative dataMean surgical time (min) 242 (111–504Mean EBL (mL) 189 mL (10–600)Open conversion 6 (8%)Major bleeding 4 (5.3%)Approach

Transperitoneal 67Retroperitoneal 8

Collecting system repair 44 (58.6%)WIT (min)

Total 30.1Range 13–55

Collecting system repairYes 34.6No 26.4

ostoperative dataHospital stay (days) 2.7 (1–15)Foley catheter (days) NAComplications

Urine leak 2 (2.7%)Bleeding 3 (4%)BNCUrinary retention

EY: LPN � laparoscopic partial nephrectomy; RLRP � robotic laparoscopic radicastimated blood loss; WIT � warm ischemia time.Excluded open conversion cases and sural nerve grafting.

eritoneally, with a mean operative time of 224 n

10

inutes (range 170 to 460) and a mean esti-ated blood loss of 36 mL (range 7 to 100). Seven

atients (50%) had crossing vessels. No intraoper-tive complications of bleeding or open conver-ions occurred. No postoperative urinary leakseveloped. One patient had postoperative bleed-

ng treated conservatively. At a mean follow-upf 14 months, all patients had had symptom im-rovement and had improved to stable renal func-ion on their 3-month mercaptotriglycylglycine re-

ts who underwent LPN, RLRP, and LPRLRP LP

300 14

59.3 (42–74) 38 (22–61)

300 8— 6

— 7— 7

236 (78.7%)50 (16.7%)14 (4.6%)6.3 (0.6–32)

236 (78.7%)57 (19%)5 (1.7%)2 (0.6%)

295* (143–525) 224 (170–460)303.6* (10–800) 36 (10–100)

7 (2.3%) 02 (0.7%) 0

1.53 (1–9) 1.8 (1–3)6.1 NA

3 (1%) 03 (1%) 1 (7.1%)4 (1.4%)3 (1%)

atectomy; LP � laparoscopic pyeloplasty; PSA � prostate-specific antigen; EBL �

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COMMENT

In the past decade, numerous refinements in in-trumentation and surgical techniques have allowedor wider application of laparoscopic surgery. Evenhough ablative laparoscopic techniques have be-ome increasingly more common, the widespreadse of reconstructive laparoscopy is still evolving.his is because of the high level of difficulty related to

ntracorporeal suturing and knot tying in proceduresuch as LPN, LRP, RLRP, and LP.For LPN, reconstructive surgery is performed

uring WIT, the most critical portion of the proce-ure. During this time, tumor excision and preciseuturing must be completed within a 30-minuteeriod before the renal parenchyma may sustainamage.8 Conventional closure of the collectingystem and the renal parenchyma is performedith sutures that are tied intracorporeally.9 How-

ver, intracorporeal knot tying is time consumingnd may result in prolonged WIT. In addition, withonventional knot tying, because the knots are fas-ened onto the renal parenchyma with an upwardorce, a “cheese-slicing” effect can occur in whichhe sutures may cut through the renal parenchyma,ausing more bleeding (Fig. 1). Worse yet, the su-ures can tear out completely during fastening ofhe knot. Using the LTc to cinch down on the renalarenchymal defect closure with one throw avoidshis cheese-slicing effect. The force required to op-ose the tissue is parallel to the kidney rather thanangential. However, one needs to perform theinching with great care, because overdue forceay pull the LTc through the renal parenchyma.uring laparoscopic intracorporeal knot tying, thenot may loosen before the second knot is laidown, resulting in a loose suture. This will result innefficient time consumption during warm isch-mia. In the case in which further cinching is

IGURE 1. Laparoscopic repair during partial nephrecension in line with capsular surface. (B) Intracorporeaicular to capsular surface. These forces (arrows) may

eeded, placing an additional LTc proximal along g

ROLOGY 68 (3), 2006

he same suture allows for collecting system coap-ation and parenchymal compression. Such a ma-euver cannot be done once a square knot has been

astened with conventional knot tying. Thus, usinghe LTc, we could avoid many of these potentialroblems while achieving rapid closure of the renalefect.In our series, we used our knot-free method for

epair of the collecting system and renal paren-hyma in patients undergoing LPN. Our overallean WIT was 30.1 minutes in a group of patientsith a mean tumor size of 2.53 cm. Collecting sys-

em closure was required in 58.6% of all patients.uch results compared equally with those of otherroups in which conventional suturing was per-ormed. In a recent publication by Moinzadeht al.,10 the WIT was 27 minutes in a group of 100atients with a mean tumor size of 2.9 cm, and5% required pelvicaliceal closure. Despite similarITs, it was difficult to isolate the effect of LTcs

n improving the operative time. Other factorsuch as tumor size and location, the need for col-ecting system closure, and the use of additionalemostatic techniques such as Surgicel bolsters,rgon laser coagulation and FloSeal, as well as sur-ical experience, must be considered. Although weid not have a cohort of patients in which knotying was performed to compare the WITs, we didemonstrate low postoperative complication rateselated to collecting system and parenchymal clo-ure. Postoperatively, 2 patients had urinary leak-ge (2.6%) and 3 had postoperative bleeding (4%).our patients had uncontrollable bleeding intraop-ratively and required urgent open conversion5.3%). These complications compared favorablyith other groups in which acute or delayed hem-rrhage and urinary leakage was reported to be as

y. (A) Placement of LTc on suture that is placed undert that, when fastened, delivers upward forces perpen-through parenchyma (cheese slicing).

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reat as 9.5% and 4.5%, respectively.10,11

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During laparoscopic radical prostatectomy, mosturgeons use a double-arm continuous runningnastomosis.12 Appropriate tension must be main-ained on the suture for watertight closure. Ten-ion may be lost when the surgeon performs intra-orporeal knot tying when throwing the knot.imilarly, because of the inability of the robot toransmit tactile sensation, it is difficult for the sur-eon to judge the ideal suture tension. These fac-ors may lead to postoperative urinary leakage. Inur series, the assistant was able to follow the sur-eon and keep a constant tension on the suturentil it was ready to be locked with an LTc. TheTc was applied with a handheld device that allowshe assistant surgeon to appreciate the tissue resis-ance and suture tension. In the event the first LTcas inadequately placed, the tension can be in-

reased by the application of a second, more prox-mal clip. We have performed all vesicourethralnastomoses in this fashion. Although we haveeen unable to demonstrate quicker anastomosisimes, our technique with the LTc has demon-trated low anastomotic complication rates. Theoley catheters were removed at a mean of 6.1ays. Our urine leak rate of 1% compared favorablyith those of published RLRP series at 8.9% to0%.13,14 Similarly, we report a very low bladdereck contracture rate of 1.4%.In our LP series, 14 successful dismembered py-

loplasties were performed without complicationsr postoperative urinary leakage. Our results com-are with those of contemporary series. The mostecent and largest published series to date, fromohns Hopkins, reviewed their experience of 147Ps between 1993 and 2000. With a mean fol-

ow-up of 24 months, the overall success rate for allatients with primary ureteropelvic junction ob-truction was 95%.15 Complications were noted in1 patients, of whom 2 had urinary leakage1.35%). The ability to quickly and reliably pro-ide the ideal suture tension for collecting systemlosure may explain the lack of urinary leakage inur group.Some may be concerned about the potential for

alculus formation using the LTc. However, thebsorbable clip is never in contact with the urine. Itimply rests on the outer aspect of the tissue. Oneeport of a ureteral pseudodiverticulum with theTc has been published16; however, such an eventccurred in a patient who had previously under-one laparoscopic nondismembered pyeloplastynd antegrade endopyelotomy, complicated byostoperative bacteruria and funguria. Dismem-ered pyeloplasty was then performed, again withhe use of the LTc, and was complicated by anas-omotic extravasation and infection. As such, weelieve the LTc can be safely used in all patients

ith primary and uncomplicated secondary uret- fi

12

ropelvic junction obstruction. In patients inhom the initial treatment has been fraught with

nfection, leading to poor tissue quality at recon-truction, the use of the LTc should be avoided.Finally, it must be noted that the LTc can be used

n other instances of reconstructive laparoscopicurgery when knot tying is needed. A 4-0 Proleneuture with an LTc placed at the end can be used touickly and efficiently repair venous injuries, lim-ting blood loss. In our experience, a 1-cm venaaval laceration during retroperitoneal pelvicymph node dissection and a 5-mm laceration in aeft iliac vein during pelvic lymph node dissectionere safely and rapidly repaired using this method.sing conventional knot tying methods could po-

entially take longer and increase the blood loss.e have also used this method for bladder closure

fter partial cystectomy in 2 cases.Our study had limitations. Because of the retro-

pective nature of the study, a comparative analysisetween a control group and randomization wereot possible. Selection bias may have played a role

n the LP group. However, the data were all inclu-ive, and no patients were excluded. Because of theack of a cohort of patients in whom conventionalnot tying was used, we were unable to demon-trate a shorter WIT or faster vesicourethral anas-omosis or ureteropelvic junction reconstructionime in our patients.We have demonstrated in our series that one of

he most technically challenging tasks, intracorpo-eal knot tying, can be safely and efficiently supple-ented by a simpler method. Using LTcs, we have

hown that we can secure the collecting system andchieve parenchymal hemostasis in LPN and create aatertight vesicourethral anastomosis in LRP and LP.he LTc allows the surgeon the ability to adjust su-

ure tension, unlike during knot tying. Although weere unable to demonstrate a clear time advantageith the use of the LTc, our results favor low com-lication rates related to hemostasis and watertightrothelial closure. The LTc system does not, how-ver, eliminate the need for intracorporeal knot-ying skills. LTc supplements this invaluablekill. We believe this method may make difficulteconstructive laparoscopic procedures easier toerform for urologists embarking on these pro-edures.

CONCLUSIONS

Our results have shown that the use of the LTcimplifies and allows safe and efficient perfor-ance of complex urologic laparoscopic proce-

ures. It may allow more urologists to embark oneconstructive laparoscopic procedures with con-

dence. We believe it is an essential aspect of the

UROLOGY 68 (3), 2006

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REFERENCES1. DeKernion J: “Management of Renal Cell Carcinoma”

lenary session. Presented at the American Urological Associa-ion Annual Meeting, San Francisco, California, May 8–13, 2004.

2. Clayman RV, Kavoussi LR, Soper NJ, et al: Laparo-copic nephrectomy. N Engl J Med 324: 1370–1371, 1991.

3. Andrews SM, and Lewis JL: Laparoscopic knot substi-utes: an assessment of techniques of securing sutures throughhe laparoscope. Endosc Surg Allied Technol 2: 62–65, 1994.

4. Anderson KR, and Clayman RV: Laparoscopic lowerrinary tract reconstruction. World J Urol 18: 349–354, 2000.

5. Orvieto MA, Chien GW, Laven B, et al: Eliminatingnot tying during warm ischemia time for laparoscopic partialephrectomy. J Urol 172: 2292–2295, 2004.

6. Chien GW, Orvieto MA, Galocy RM, et al: Antegradeerve preservation during robotic assisted laparoscopic radi-al prostatectomy. Video presented at the American Urologi-al Association Annual Meeting, San Francisco, California,ay 8–13, 2004.

7. van Velthoven RF, Ahlerigh TE, Peltier A, et al: Tech-ique for laparoscopic running urethrovesical anastomosis:he single knot method. Urology 61: 699–702, 2003.

8. Novick AC: Renal hypothermia: in vivo and ex vivo.

rol Clin North Am 10: 637–644, 1983. 2

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9. Gill IS, Desai MM, Kaouk JH, et al: Laparoscopic partialephrectomy for renal tumor: duplicating open techniques.Urol 167: 469–471, 2002.10. Moinzadeh A, Gill IS, Finelli A, et al: Laparoscopic par-

ial nephrectomy: 3-year followup. J Urol 175: 459–462,006.11. Gill IS, Matin SF, Desai MM, et al: Comparative analysis

f laparoscopic versus open partial nephrectomy for renal tu-ors in 200 patients. J Urol 170: 64–68, 2003.12. Hoznek A, Salomon L, Rabii R, et al: Vesicourethral

nastomosis during laparoscopic radical prostatectomy: theunning suture method. J Endourol 14: 749–753, 2000.

13. Ahlering TE, Skarecky D, Lee D, et al: Successful trans-er of open surgical skills to a laparoscopic environment usingrobotic interface: initial experience with laparoscopic radicalrostatectomy. J Urol 170: 1738–1741, 2003.14. Bentas W, Wolfram M, Jones J, et al: Robotic technol-

gy and the translation of open radical prostatectomy to lapa-oscopy: the early Frankfurt experience with robotic radicalrostatectomy and one year follow-up. Eur Urol 44: 175–181,003.15. Inagaki T, Rha KH, Ong AM, et al: Laparoscopic pyelo-

lasty: current status. BJU Int 92(suppl 2): 102–105, 2005.16. Finley DS, Perer E, Eichel L, et al: Ureteral pseudodi-

erticulum associated with absorbable suture clips after lapa-oscopic pyeloplasty: case report. J Endourol 19: 726–729,

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